Renal

Question 0

Myeloma kidney types/causes

Answer 0

SEVERITY OF RENAL DYSFUNCTION CORRELATES WITH PATIENT SURVIVAL

Myeloma cast nephropathy (tubular)
Amyloidosis (glomerular)
Monoclonal immunoglobulin deposition disease (glomerular)
Also plasma cell infiltration (interstitial)

Renal failure also from hypercalcaemia, hyperuricaemia, drugs

Isolated tubular dysfunction often in light chain disease-proximal mostly- giving RTA and maybe acquired Fanconi syndrome
Also interstitial nephritis (interstitial)

Question 1

Why would you do an abdominal fat pad aspirate?

Answer 1

If you are thinking AL Amyloidosis

• nephrotic range proteinuria
• peripheral sensorimotor neuropathy
• autonomic neuropathy
• carpal tunnel
• peri orbital purpura
• diarrhoea and malabsorption
• macroglossia
• heart failure

Question 2

Type of renal dysfunction associated with pamindronate

Answer 2

Focal segmental glomerulosclerosis

Question 3

4 induction drugs

Answer 3

Steroids
Cyclophosphamide
MMF
rituximab- refractory

Question 4

Side effects cyclophosphamide

Answer 4

Gonadal toxicity
Major infection
HZV
bladder toxicity
Malignancy 
Bone marrow suppression

Question 5

Mechanism of probenecid increasing plasma concentration of drugs like penicillin and oseltamivir

Answer 5

Inhibits organic anion excretion in proximal tubule

Question 6

Mechanism of increased creatinine in trimethoprim and cimetidine

Answer 6

Atp dependent transporter called P glycoprotein on brush border membranes secretes lots of drugs as well as creatinine and neurotransmitters. No change in actual gfr, the creatinine is just not being secreted

Question 7

Abx choice in infected cyst in PCKD

Answer 7

Good pathogen cover AND good cyst penetrance
Cipro
Differentiate between ruptured cyst which has mild fever, some flank pain but usually no white cell count

Question 8

Rasburicase mechanism in tumour lysis

Answer 8

Breaks down Uric acid and minimises xanthine accumulation

Question 9

FSGS - what do you see in the urine.

Answer 9

Microscopic haematuria, hypertension, kidney insufficiency

Question 10

IgA nephropathy - secondary causes include

Answer 10

Chronic liver disease
Coeliac
HIV
IBD

Question 11

Effects of anaemia in Ckd

Answer 11

LVH
REDUCED QOL
cv complications

Question 12

Causes of distal RTA

Answer 12

Autoimmune disorders
Lithium or amphotericin
Hypercalciuria
Hyperglobulinaemia

Also see nephrocalcinosis and urine PH over 6 in type 1

Question 13

Gitleman syndrome

Answer 13

Looks like thiazide effect on kidney
Autosomal recessive
Hypokalaemic metabolic alkalosis
BP low
Low mg 
Inactivating mutation in sodium chloride cotransporter in DCT

Question 14

Cyclosporine A toxicity renal mech

Answer 14

Constrict adherent and efferent arterioles
Hypertension with high levels
HUS class effect
Chronic toxicity irreversible
Path changes- arteriolar hyalinosis, glomerulosclerosis, interstitial fibrosis, “striped fibrosis” TGF beta and Ang II mediated
Also risk hyperkalaemia, hyperuricaemia, metabolic acidosis, low mg, low phosphate

Question 15

Name some interstitial nephritis drugs

Answer 15

NSAIDs - even after months exposure. Due to leukotriene increase. Can cause minimal change picture
Aminoglycosides- saturable tubular uptake so single large doses therefore better
Lithium
Amphotericin
Gentamicin
Antivirals- use entecavir over indinavir in HAART if CKD 3 or above. Causes ATN also, low phosphate, low my, increase creatinine, glycosuria
Ppi

Question 16

Fanconi syndrome

Answer 16

Disease of proximal renal tubules.
Loss glucose, amino acids, Uric acid, phosphate, bicarb in urine
Type 2 RTA
LOSS PHOSPHATE leads to Ricketts
Clinical features polyuria, polydipsia, acidosis, growth failure, low K, high Cl
Inherited- cystinosis, Wilsons, glycogen storage diseases
Acquired- tenofovir, lead poisoning, expired tetracycline, mm or MGUS

Question 17

Cisplatin and toxicity mech

Answer 17

Renal tubular toxin from free radical formation And CKs
Mg wasting
HUS

Question 18

Time frame interstitial nephritis and PPI

Answer 18

Usually three months

Sometimes up to nine months

Question 19

Penicillamine renal side effect

Answer 19

Membranous

Question 20

Renal effect with VEGF inhibitors…. What is it?

Answer 20

Podocyte damage- see thickened BM with podocyte effacement
Need to monitor for proteinuria
Eg bevacizumab

Question 21

Hydralazine renal side effect

Answer 21

Drug induced lupus

Question 22

Trimethoprim effect on potassium

Answer 22

Increase- even in normal renal function

Question 23

Risk of gadolinium in renal failure

Answer 23

Contraindicated if GFR less than 30 due to risk of nephrogenic systemic fibrosis. Dialyse soon after if possible. 2-75 days from exposure, median 25. Most cases with gadodiamide- less risk with gadobenate

Question 24

minimal change disease drug and secondary causes

Answer 24

Drug: NSAIDs and bisphosphonates malignancy: usually primary haematological - resolution with control of malignancy

Question 25

Tests in RPGN

Answer 25

``` Anca ANA and dsDNA Complement IgA Phospholipase A2 receptor ab HCV HBV anti GBM ab Anti DNase B, ASOT Cryoglobulins ```

Question 26

High anion gap METABOLIC ACIDOSIS

Answer 26

GOLD MARK glycols- propylene and glycolene Oxolene- paracetamol in malnourished ladies chronic L- lactate- infusion metabolism phenobarbotone or lorazepam when solute propylene glycol d lactate- short gut syndrome Methanol Aspirin Renal failure Ketoacidosis

Question 27

Normal anion gap MA | 8-13

Answer 27

Loss bicarb- diarrhoea, CA Inhibitors, type 2 RTA, pancreatic ileostomy, pancreatic or biliary or intestinal fistula Exogenous admin HCl or ammonium chloride Decreased renal acid excretion- type 1 and 4 RTA, renal failure. Hyperkalaemia Recovery fromDKA

Question 28

Urine anion gap use

Answer 28

Differentiate between renal and gut causes of hyperchloraemic MA GUT uag will be neGUTive Renal distal accidification problem will be positive Normal is zero or neg This is because AG estimates loss of Cl as marker of ammonium in urine. If renal problem cannot do this so positive gap

Question 29

Distal RTA

Answer 29

``` Autoimmune HyperPT, vit D toxicity Thyroid disorders Hypergammaglobulinaemia Amphotericin, lithium, ifosfamide, PPI, NSAIDs Chronic hep Obstructive uropathy Sickle cell Renal Tx ```

Question 30

Type 2 RTA

Answer 30

``` Often assoc Fanconi MM contrast agents Adenovir, tenofovir Aminoglycosides Rhabdo Heavy metals Amyloid Interstitial nephritis ```

Question 31

Causes type 4 RTA

Answer 31

Acquired: decreased renin from diabetic nephropathy, NSAIDs, interstitial nephritis Acquired: normal renin reduced aldosterone in ACE ARB heparin Acquired: decreased response aldosterone in K sparing diuretics, trimethoprim, tac, pentamidine, tubulointerstitial disease- sickle cell, SLE, amyloid, DM

Question 32

Warfarin in AF and esrf?

Answer 32

High rates GI bleeding in these patients. | Retrospective cohort in Circulation 2014 Jan- suggested higher rate haemorrhagic stroke and other bleeds, need RCT

Question 33

Consider formation vascular access when...

Answer 33

Patient likely to live more than one year and gfr less than 20

Question 34

Benefits of PD over HD

Answer 34

``` Preserve RRF cheaper Less inflammation Less infection Independence and employment Even volume and BP control Increase in early graft function post Tx Reduce EPO/ iron Preserve vascular access ```

Question 35

FIVE MAIN EFFECTS OF RENAL BONE DISEASE

Answer 35

``` Bone Anaemia Fluid Electrolytes Waste retention ```

Question 36

Degree of RAS needed to induce Renal ischaemia and activate RAAS

Answer 36

Over 75 percent

Question 37

Three drugs most well known for drug induced lupus

Answer 37

Hydralazine Procainamide Isoniazid ... Arthralgia and arthralgia, pericarditis and pleuritic, ANTI HISTONE AB IN 95%

Question 38

Why do you give amiloride in nephrogenic diabetes insipidus caused by lithium

Answer 38

Directly blocks ENaC and decrease tubular uptake of lithium leading to reduced long term damage

Question 39

Differential metabolic acidosis plus resp alkalosis combined

Answer 39

Liver disease Sepsis Salicylate toxicity

Question 40

Indications for dialysis

Answer 40

Uraemic symptoms Acidosis refractory to medical therapy Fluid overload refractory Electrolyte disturbance not easily managed with medications Progressive deterioration in nutritional status refractory to dietary intervention Also: refractory bp control and cognitive impairment

Question 41

How is urine pH important in urine infection suspicion

Answer 41

If over 7 suggest urease splitting organism like proteus or pseudomonas Also highly alkaline urine can cause false positive dipstick

Question 42

ABO incompatibility- is it a contraindication to transplantation

Answer 42

No - do just as well!

Question 43

Benefits of transplantation

Answer 43

improved long term survival comp dialysis- if fit for it QOL- independence from dialysis and fluid restriction, work, feel better Cheaper after 1st year

Question 44

Complications of ADPCKD

Answer 44

UTI risk- GIVE CIPRO Renal cyst rupture -->pain or haematuria Hypertension and proteinuria and compl of CKD ESKD- 50s for PCK-1 and 70s for PCK-2 Thoracic aortic dissection, cervico-cephalic, coronary artery aneurysms MV prolapse and AI IC aneurysms- screen with MRA if family history, neuro sx, or high risk like pilot.

Question 45

What is the most significant cause of renal anaemia?

Answer 45

reduced EPO synthesis